In the course of my work, I have been overwhelmingly impressed with the extent to which America is a bottom-up society, that is, where new trends and ideas begin in cities and small communities, not New York City or Washington, D.C. My colleagues and I have studied this great country by reading the local newspapers. We have discovered trends are generated from the bottom-up, fads from the top-down.
John Naisbtt, Megatrends: Ten New Directions Transforming Our Lives, 1980
I admire the writings of futurist John Naisbitt, in Megatrends (1980) and Mindset! (2007), for Naisbitt understands, more than anyone I know, the importance of altitudes and attitudes.
In discussing the politics of health care, it is crucial to understand altitudes, as seen from above, and attitudes, as viewed from the grassroots, for the two are inextricably intertwined. Nowhere is this more evident than in health care.
If you start from a top-down altitude, whether that be in Washington, D.C, the rarified heights of a think-tank, or a command-and-control corporate or helaht plan board rooms, you have a certain mindset, that you know best what should be done at the grassroots. It is an easy trap to fall into, for you command the heights of decision-making, for that is what you are paid to do, and you either pay the bills or advise those who do.
Consider those who control national health and corporate health policies. In 1965, America decided Medicare and Medicaid officials would henceforth know best what was good for the old, the poor, and the disabled. Roughly ten years later, managed care started in earnest, and business payers decided that health care decision-making in the streets, hospitals, doctors offices, and other myriad care locations was too important to be left to patients and doctors.
In all of these setting, the altitude dictates the attitude- the mindset of the powers that be. To a large extent, these altitudes and attitudes are understandable. For every social tasske of importance is entrusted to large institutions organized for perpetuity and run by political leaders and managers. But we are an individualist society, dominated by pluralistic forces. And as time has passed, patients, as well as physicians, have become increasingly critical , disenchanted, and suspicious of the ability to top-down powers to perform, to understand what is transpiring on the ground, and to use tools such as information technologies, to control and guide what wells up from below.
The consequences of these differing views from different altitudes and attitudes has been a giant disconnect –a yawning chasm between those above who profess to know and those who practice below.
Take managed care as an example. Those who profess to know first thought costs could be controlled and channeled by restricting utilizations and dampening referrals to specialists and hospitals. This set of attitudes has been a colossal failure because of a misunderstanding of American culture. Now those who profess to know have changed course and have decided the best way to control costs and better care lies in concentrating and coordinating course is through primary care offices and through offering small rewards for “performance.” Small wonder, given the track record of managed care, that doctors harbor dark suspicions that this too may not work.
It does not seem to have dawned on top-down decision-makers that that the primary care professions, due to a series of missteps from above – burdensome and expense-producing rules and regulations requiring large office staffs, misguided reimbursements, over-reliance on high tech, a worship of data, and a lack of respect – has thrown the primary care professions into total disarray, indeed on verge of destruction, because primary care no longer appeals to pragmatic struggling doctors.
Nor has the idea seem to set in that doctors, as members of a profession, do not respond to small financial incentives to perform higher quality care. For God’s sake, they say, that is what we are obligated to do in the first place. And neither do we respond to giant check lists sent down from above to tell us how to manage patients, or to anguished cries of uneven “quality,” as defined by payers sending down proclamations. We are doctors, not airline pilots, and we march to our own drummer – what’s good for the patients.
Doctors want understanding of what top-down meddling has wrought – overworked physicians, overcrowded offices, misguided reimbursements, over-written rules that often serve no useful purpose, incentives that don’t incent and may even dis-incent, and over-engineered medical record systems that are neither patient or doctor friendly.
Wednesday, August 27, 2008
Sunday, August 24, 2008
Twelve Physician Sensibilities
The capacity to feel or perceive: the capacity to respond emotionally or aesthetically.
Sensibility, Dictionary definition
The average physician perspective is this. I went to medical school I’m loaded with debt. I’ve got an office full of people pushing paper every day. I don’t have time to talk to anybody. Nobody in Washington seems to care what I think. I can’t function this way. I don’t egt reimbursed enough.
Arthur Caplan, PhD, Professor of Bioethics at the University of Pennsylvania, “Shattuck Lecture: Health of the Nation” Coverage of All Americans, “ New England Journal of Medicine. August 21, 2008
Research suggests that the presence and support of a robust primary care system is a major characteristic of an efficient and high-quality health care delivery. However, the future of the US primary care system is uncertain at best and is perilously close to collapse at worst. Fewer medical students and residents are choosing primary care specialties, and physicians in practice are leaving internal medicine faster than their other colleagues with a subspecialty.
Michael S. Barr, MD, MBA, VP, Patient Advisory and Improvement, American College of Physicians, “The Need to Test the Patient-Centered Medical Home, “ JAMA, August 20, 2008.
People tell me I clearly grasp physician sensibilities. That may or may not be true. You be the judge.
Sensibility One - The public and policy makers have little understanding of the depth and breadth of physician demoralization and dissatisfaction, particularly among primary care clinicians. This misconception may be remedied soon by a survey of 300,000 primary care physicians by the Foundation of Health System Excellence, a nonprofit organization representing state and local medical societies. The survey covers physician attitudes, levels of satisfaction, socioeconomic status, and state of U.S. health care.
Sensibility Two – Physicians are either not entering or fleeing primary care in record numbers. This will soon lead, if it has not already, a widespread primary care shortage and will precipitate an access crisis.
Sensibility Three – Universal coverage and comprehensive coordinated care is meaningless with access to primary care physicians, a problem now manifest and playing out in Massachusetts, and beginning to be addressed by policy makers and members of the medical academic establishmment.
Sensibility Four – Dissatisfaction with care is rampant among primary care physicians, who yearn to spend more time with patients and to bet off the current productive line practices, requiring them to see 20 to 30 patients a day. Much of this unhappiness stems from a reimbursement system that rewards high-tech procedures rather than cognitive care and time spent with patients.
Sensibility Five - The reimbursement system falls to pay physicians for such vital things as same-day appointments, and telephone and email consultations. In the case of telephone calls, this is absurd since many physicians spend at much as ¼ to 1/3 of their time on the phone.
Sensibility Six - A growing and unknown number of primary care physicians are opting out of HMOs, PPOs, and other third party arrangements, seeking refuge in concierge and cash-only practices to escape the harassment and overheads involved in dealing with third parties.
Sensibility Seven - Malpractice fears reap havoc, both psychologically and economically, because it engenders mutual distrust and fosters defensive medicine to avoid future malpractice actions, while doing little to protect patients against harm..
Sensibility Eight - Medicare and other federal programs, because of their size, scope, impersonal, and bureaucratic nature, are recipes for fraud and abuse. Scam artists – and rarely opportunistic patients, doctors, hospitals, and entrepreneurs – often “game” the system, resulting, among other things, in vast overruns in Durable Medical Equipment businesses.
Sensibility Nine - Many physicians instinctively distrust information technologies as instruments for savings and safety because they tend to benefit health plans and because of high costs of installation, training, maintaining, practice disruptions, low returns on investment, limitations in communicating with colleagues and hospitals, and their secret suspicion that these technologies may serve as vehicles for monitoring, punishing non-compliance, rating doctors, and excluding doctors.
Sensibility Ten - The potential value of virtual e-medicine in treating and consulting with patients over the Web rather than seeing them face-to-face is squandered and is often meaningless because Medicare and most health plans do not pay for virtual visits.
Sensibility Eleven - The savings of prevention, with the exception of smoking cessation, may be over-estimated because physicians are not paid for counseling patients, many patients do not like to be lectured on life style, and many resume harmful behaviors after they leave the doctor’s office or hospital. Besides preventing disease, though it saves money in the short run, may cost more in the long run because of costs of treating the elderly.
Sensibility Twelve – The Medical Home concept, is laudable because it places patients and primary care doctors at the center of coordinated care. Current pilot studies should be continued, but doctors fear the process has become too “political” and too bureaucratic. Doctors are acutely aware of the tremendous investment in information infrastructure and staff required and uncertainly of rules and rewards entailed.
Sensibility, Dictionary definition
The average physician perspective is this. I went to medical school I’m loaded with debt. I’ve got an office full of people pushing paper every day. I don’t have time to talk to anybody. Nobody in Washington seems to care what I think. I can’t function this way. I don’t egt reimbursed enough.
Arthur Caplan, PhD, Professor of Bioethics at the University of Pennsylvania, “Shattuck Lecture: Health of the Nation” Coverage of All Americans, “ New England Journal of Medicine. August 21, 2008
Research suggests that the presence and support of a robust primary care system is a major characteristic of an efficient and high-quality health care delivery. However, the future of the US primary care system is uncertain at best and is perilously close to collapse at worst. Fewer medical students and residents are choosing primary care specialties, and physicians in practice are leaving internal medicine faster than their other colleagues with a subspecialty.
Michael S. Barr, MD, MBA, VP, Patient Advisory and Improvement, American College of Physicians, “The Need to Test the Patient-Centered Medical Home, “ JAMA, August 20, 2008.
People tell me I clearly grasp physician sensibilities. That may or may not be true. You be the judge.
Sensibility One - The public and policy makers have little understanding of the depth and breadth of physician demoralization and dissatisfaction, particularly among primary care clinicians. This misconception may be remedied soon by a survey of 300,000 primary care physicians by the Foundation of Health System Excellence, a nonprofit organization representing state and local medical societies. The survey covers physician attitudes, levels of satisfaction, socioeconomic status, and state of U.S. health care.
Sensibility Two – Physicians are either not entering or fleeing primary care in record numbers. This will soon lead, if it has not already, a widespread primary care shortage and will precipitate an access crisis.
Sensibility Three – Universal coverage and comprehensive coordinated care is meaningless with access to primary care physicians, a problem now manifest and playing out in Massachusetts, and beginning to be addressed by policy makers and members of the medical academic establishmment.
Sensibility Four – Dissatisfaction with care is rampant among primary care physicians, who yearn to spend more time with patients and to bet off the current productive line practices, requiring them to see 20 to 30 patients a day. Much of this unhappiness stems from a reimbursement system that rewards high-tech procedures rather than cognitive care and time spent with patients.
Sensibility Five - The reimbursement system falls to pay physicians for such vital things as same-day appointments, and telephone and email consultations. In the case of telephone calls, this is absurd since many physicians spend at much as ¼ to 1/3 of their time on the phone.
Sensibility Six - A growing and unknown number of primary care physicians are opting out of HMOs, PPOs, and other third party arrangements, seeking refuge in concierge and cash-only practices to escape the harassment and overheads involved in dealing with third parties.
Sensibility Seven - Malpractice fears reap havoc, both psychologically and economically, because it engenders mutual distrust and fosters defensive medicine to avoid future malpractice actions, while doing little to protect patients against harm..
Sensibility Eight - Medicare and other federal programs, because of their size, scope, impersonal, and bureaucratic nature, are recipes for fraud and abuse. Scam artists – and rarely opportunistic patients, doctors, hospitals, and entrepreneurs – often “game” the system, resulting, among other things, in vast overruns in Durable Medical Equipment businesses.
Sensibility Nine - Many physicians instinctively distrust information technologies as instruments for savings and safety because they tend to benefit health plans and because of high costs of installation, training, maintaining, practice disruptions, low returns on investment, limitations in communicating with colleagues and hospitals, and their secret suspicion that these technologies may serve as vehicles for monitoring, punishing non-compliance, rating doctors, and excluding doctors.
Sensibility Ten - The potential value of virtual e-medicine in treating and consulting with patients over the Web rather than seeing them face-to-face is squandered and is often meaningless because Medicare and most health plans do not pay for virtual visits.
Sensibility Eleven - The savings of prevention, with the exception of smoking cessation, may be over-estimated because physicians are not paid for counseling patients, many patients do not like to be lectured on life style, and many resume harmful behaviors after they leave the doctor’s office or hospital. Besides preventing disease, though it saves money in the short run, may cost more in the long run because of costs of treating the elderly.
Sensibility Twelve – The Medical Home concept, is laudable because it places patients and primary care doctors at the center of coordinated care. Current pilot studies should be continued, but doctors fear the process has become too “political” and too bureaucratic. Doctors are acutely aware of the tremendous investment in information infrastructure and staff required and uncertainly of rules and rewards entailed.
Friday, August 22, 2008
A “Personal Physician” Speaks, Everything's in the Name
There is no other profession as personal as the medical profession. It physicians continue to allow non-physicians and businesses such as hospitals and insurers to control them, they will lose their patients and will nothing more than over-educated technicians.
Donald Copeland, MD, Innovation-Driven Health Care: 34 Concepts for Transformation, (Jones and Bartlett, 2007)
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Yesterday I was speaking to Don Copeland, a friend and a family physician, in North Carolina. My wife says of Don, “When I get sick, Dick, I want Don as my personal doctor.” Don is a fine physician, beloved by patients. He takes their best interests to heart and acts accordingly.
A “personal physician” is exactly what Don considers himself to be – nothing more, nothing less. He thinks of a personal physician as a personal guide, confidante, and trusted advisor. He thinks of the personal physician-patient relationship as a spiritual bond, best left untouched and untouchable by remote third parties.
Don insists the very terms, “primary care physician” and “provider” are misnomers. The proper designation ought to be “personal physician.” Don is equally disdainful of the adjecti ve “cognitive” and “proceduralist” as applied to personal physicians. A personal physician, after all, may perform procedures in the office, sparing his patients the inconvenience, expensive, delays, and paperwork involved in needless referrals.
Besides, any physician, not matter what he is named or how he is characterized, ought to have the liberty to charge directly for his services, which is the reason, Don champions health savings accounts. Don even has visions of starting a national HSA organization in collaboration with community banks.
Don maintains, and rightly so, that doctors and patients lie at the very core of the health system. Government bureaucrats , health plan executives, and hospital leaders are secondary players, who depend on doctors. Somehow, in the process of labeling doctors as “primary” and “provider,” these players have over-played their hands, and reduced a noble profession to a dec idedly impersonal business.
It may take a while for these big players to see the error of their ways. Unitl then, I'm reminded of a Casey Stengel tale. After managing the world champion Yankees, Casey managed the lowly Mets. Marv Thornberry was one of his hapless crew. Casey was disgusted with Marv's playing and decided to show him how things were done. Casey took to the field, had a fungo fly hit to him -- and dropped the ball. He turned to Thornberry and shouted, "Marv, you've got this position so fowled up, nobody can play it!" The same may hold true for payers who have placed physicians on the field of play as quasi-employees.
--------------------------------------------------------------------------------
There is no other profession as personal as the medical profession. It physicians continue to allow non-physicians and businesses such as hospitals and insurers to control them, they will lose their patients and will nothing more than over-educated technicians.
Donald Copeland, MD, Innovation-Driven Health Care: 34 Concepts for Transformation, (Jones and Bartlett, 2007)
< o:p>
Yesterday I was speaking to Don Copeland, a friend and a family physician, in North Carolina. My wife says of Don, “When I get sick, Dick, I want Don as my personal doctor.” Don is a fine physician, beloved by patients. He takes their best interests to heart and acts accordingly.
A “personal physician” is exactly what Don considers himself to be – nothing more, nothing less. He thinks of a personal physician as a personal guide, confidante, and trusted advisor. He thinks of the personal physician-patient relationship as a spiritual bond, best left untouched and untouchable by remote third parties.
Don insists the very terms, “primary care physician” and “provider” are misnomers. The proper designation ought to be “personal physician.” Don is equally disdainful of the adjecti ve “cognitive” and “proceduralist” as applied to personal physicians. A personal physician, after all, may perform procedures in the office, sparing his patients the inconvenience, expensive, delays, and paperwork involved in needless referrals.
Besides, any physician, not matter what he is named or how he is characterized, ought to have the liberty to charge directly for his services, which is the reason, Don champions health savings accounts. Don even has visions of starting a national HSA organization in collaboration with community banks.
Don maintains, and rightly so, that doctors and patients lie at the very core of the health system. Government bureaucrats , health plan executives, and hospital leaders are secondary players, who depend on doctors. Somehow, in the process of labeling doctors as “primary” and “provider,” these players have over-played their hands, and reduced a noble profession to a dec idedly impersonal business.
It may take a while for these big players to see the error of their ways. Unitl then, I'm reminded of a Casey Stengel tale. After managing the world champion Yankees, Casey managed the lowly Mets. Marv Thornberry was one of his hapless crew. Casey was disgusted with Marv's playing and decided to show him how things were done. Casey took to the field, had a fungo fly hit to him -- and dropped the ball. He turned to Thornberry and shouted, "Marv, you've got this position so fowled up, nobody can play it!" The same may hold true for payers who have placed physicians on the field of play as quasi-employees.
--------------------------------------------------------------------------------
Viewing the Hospital of the Future through the Lens of Complexity
View your system through the lens of complexity.
Brenda Zimmerman, Curt Lindberg, and Paul Pizek, Edgeware: Insights from Complexity Science for Healthcare Leaders (VHA, Inc, 1998)
Hospitals will no longer be expected to just diagnose disease, prescribe medications, and perform surgeries. Rather hospitals will be part wellness centers, part hospice, part nursing school, part medical group. In short, patients and their families will want integrated features from across the provider spectrum.
Molly Rowe, “The Hospital of the Future,” Healthleaders Magazine, July 11, 2008
This is my 605th blog, roughly 604 more than medical world needs, for there is surely one remains worth savoring.
Nonetheless, on the other hand, the health care system is so complex, with so many niches, gaps, crevices, crevasses, chasms, hills, valleys, tectonic faults, convexities, concavities, choices, options, perplexities, innovations, opportunities, and problems to be solved and explored, that I persist in my quest to explain what is going on, in this case, with the hospital of the future.
In Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007), I devoted four chapters to hospital innovations.
• “From Hospitals to Physician-Integrated Hospitals” – In it I posed two big questions for hospitals and doctors: integration or disintegration? I suggest one possible solution: join together as equity partners in a large 25,000 to 50,000 ambulatory square foot facility known as a “Big Box.”
• “Making Rooms for Boomers” – Here I described the hospital building boom of new patient and eco-friendly hospitals designed for aging babyboomers.
• “New Partners for Building and Financing Big MACCs” – Big MACCs are Multispecialty Ambulatory Care Centers build to accommodate and to cater to affluent suburban and exurban denizens in underserved medical regions.
• “From Independent Specialty Practice to Hospital Employment” – Here I dwelt on the rush of primary care doctors and specialists alike to be employed by hospitals, and the innovative possibilities and perverse incentives of this model, which has become known as the “staff model.”
From the experience of writing these chapters, I concluded; when I am re-incarnated, I do not want to be a future hospital CEO. The job will simply be too damn complex for any ordinary mortal.
The future CEO will have to be a contortionist, with a finger to the wind, an ear to the ground, one eye on the horizon, one eye on the rear view mirror, a nose in the air, and all senses focused on simultaneous competition and cooperation with physicians. As the late Peter F. Drucker commented, “One cannot run a hospital with doctors, and one cannot run one without them.”
Then, too, there’s the fundamental managerial impossibility of being all things to all people and doing all things well. As Regina Herzlinger, Harvard Business School Professor and godmother of the consumer-driven movement, has noted, hospitals cannot manage diverse numbers of sophisticated specialized activities and do them all well.
Hospitals tend to view themselves at the centerpiece of community health – as coordinator and last resort of all things related to health and disease and the only facility open 24/7 to receive all comers. This is certainly true when one thinks of the emergency room.
But options to the hospital are continually opening up, in the form of retail clinics, worksite clinics, urgent care centers, ambulatory clinics staffed by specialists, virtual home care supported by monitoring technologies, and specialist-owned hospitals. .
These options are taking their toll on hospitals, which are seeing slowing growth and drops in the number of admissions. The great migration outside the hospital, towards more consumer-friendly settings outside hospitals, is gathering a head of steam.
At the same time, physicians are flocking to hospitals to be employed. This is understandable in this age of low physician morale, economic difficulties in managing physician small businesses, the harassments of managed care, dropping health plan reimbursements, mounting accounts receivable, rising practice costs, not the least of which are onerous malpractice premiums.
But hospital employment of mass numbers of physicians has perverse incentives as well. Hospitals may take 80% of physician production as overhead. Collecting only 20% of what one produces is not a powerful incentive for physician productivity and may result in physicians taking advantages of the fringe benefits of hospital employment – a short working week, more time off, more vacation. Many primary care physicians are turning to ER and hospitalists work, but the expense of these specialists is fast becoming a significant expense burden for hospitals.
Physician employment is not a potent stimulant for reducing overall costs. To maintain growth and produce a profit margin, hospitals often insist employed physicians channel all referred work, particularly high-ticket items such as CT, MRI, and PET scans and costly cancer care to in-house specialists and facilities. Hospital services are invariably more expensive than those offered on the outside.
Still, after all is said and done, hospitals in most cases remain the largest employer in any given town, and hospitals have access to the capital needed to survive in today’s hotly competitive environment. Well-heeled specialists, however, the main strut of hospitals’ profitability, may prefer to remain independent.
As I said in the beginning, being a hospital CEO in today’s complex environment is tough. As laid out in Edgeware, the CEO job requires flexibility with a good-enough vision of what needs to be done, balancing data and risk, dealing with physician diversity and differences, honoring safety and risk, taking multiple actions at the edges, paying rapt attention to gossip and informal physician relationships, and competing and cooperating with doctors at the same tie. It’s job for the hardy and hard-headed, and for someone with a deep knowledge of the physician
Wednesday, August 20, 2008
E-Medicine for Routine Ailments: Virtual Vs. Face-to-Face Visits
A compelling reason for Internet medicine is you can treat patients without them being in your physical presence. If you’re paid for the e-visit, that may makes this form of medicine practical. For patients, benefits are convenience, time saved, being spared from parking and travel expenses.
Here, Benjamin Brewer, MD, the WSJ’s Doctor’s Office Forum blogger, discusses e-medicine.
My patient probably would have rather been anywhere else. He and his wife were in my office to discuss his erectile dysfunction for the first time.
He looked uncomfortable. For a guy who doesn't go to the doctor much, a medical office can seem as foreign and intimidating as the dark side of the moon.
His exam was normal, but he needed to quit smoking. Would it have been easier for you to fill out a questionnaire on the Internet and skip the office visit? I asked. "You bet," he replied.
The way I see it, he didn't really need to come in at all. He needed a risk assessment for heart disease, a prescription for medication, counseling and help with stopping smoking. The results would have been the same online or in person.
The average American's health-care experience is fraught with high cost, poor service and uncertain quality. But the prudent practice of medicine online would improve health care on all three counts.
Patients want access to safe, reliable medical care on the Internet, just like banking, shopping or booking a flight. Eighty percent of the public want doctors to use email to communicate with patients, but only 9% of physicians actually do that even occasionally.
I think 20% of my routine office visits could be handled safely and less expensively over the Internet. There is nothing magical about the four office walls that make face-to-face visits superior. Demanding an in-person visit for every little thing is based on tradition and consensus opinion -- not science.
Doctors trot out excuses about why they don't use the Internet as a tool for working with patients. I think doctors' big fear is that the online discussions with patients will eat up time, with little or no extra payment for the service.
A big impediment is that in most states it is illegal to prescribe drugs for a patient based on an online evaluation. That seems strange to me because physicians have been prescribing medicines by telephone for simple things without the safety net the computer provides.
Of course, there have been cases of inappropriate prescribing of narcotic medications in my home state, Illinois, and others. And regulators put the clamps on even legitimate use of Internet medicine without a face-to-face physical exam.
The medical establishment has been reluctant to embrace online medicine. Indeed, medical societies and the Federation of State Medical Boards have taken a very aggressive position against Internet prescribing in the name of patient safety. In their world, only in-person visits are thought to be safe.
Are the boards of medical examiners' policies really protecting patient safety or only mandating face-to-face office visits as economic protection for doctors, I wonder.
If I tried to prescribe ED drugs today based on an Internet questionnaire and email correspondence, the state medical board could take my license away and fine me thousands of dollars for every patient I treated.
I have no desire to be a Viagra prescription mill. I bring up the medicine because ED care over the Internet is probably the most studied of online options.
There are broader applications for Internet treatment beyond ED. And to be absolutely clear, there's no evidence that only face-to-face office visits are safe, effective and high-quality.
Traditionalists in medicine may be afraid to learn how good Internet medicine can be. One of the first substantial studies of Internet medicine was conducted by the University of Utah and published this month in the journal Mayo Clinic Proceedings. The researchers compared traditional office treatment of erectile dysfunction versus Internet practice.
The patients treated online had no face-to-face exam. The traditional doctors had the benefit of a computerized record system but they still lost out to the Internet doctors, who took a more thorough history and provided more counseling with the aide of a standardized Internet-based system.
Internet practice for ED was equal to traditional office practice or safer in all areas studied.
As a small-town doctor who still makes house calls, the prospect of an Internet practice is quite a departure from business as usual. As the Internet-savvy population ages and the number of primary care doctors dwindles, the demand for safe online medicine will grow.
Until the regulators come around to the advantages of Internet medicine, patients will continue to miss work over minor ailments and I'll keep seeing them at the office.
References
1. Benjamin Brewer MD, Internet Visits With Doctors Can Beat Office Appointments, August 20, 2008.
2. Mark Munger, et al, Safety of Prescribing PDE-Inhibitors via e-Medicine vs Traditional Medicine, Mayo Clin Pr0, August, 2008.
Here, Benjamin Brewer, MD, the WSJ’s Doctor’s Office Forum blogger, discusses e-medicine.
My patient probably would have rather been anywhere else. He and his wife were in my office to discuss his erectile dysfunction for the first time.
He looked uncomfortable. For a guy who doesn't go to the doctor much, a medical office can seem as foreign and intimidating as the dark side of the moon.
His exam was normal, but he needed to quit smoking. Would it have been easier for you to fill out a questionnaire on the Internet and skip the office visit? I asked. "You bet," he replied.
The way I see it, he didn't really need to come in at all. He needed a risk assessment for heart disease, a prescription for medication, counseling and help with stopping smoking. The results would have been the same online or in person.
The average American's health-care experience is fraught with high cost, poor service and uncertain quality. But the prudent practice of medicine online would improve health care on all three counts.
Patients want access to safe, reliable medical care on the Internet, just like banking, shopping or booking a flight. Eighty percent of the public want doctors to use email to communicate with patients, but only 9% of physicians actually do that even occasionally.
I think 20% of my routine office visits could be handled safely and less expensively over the Internet. There is nothing magical about the four office walls that make face-to-face visits superior. Demanding an in-person visit for every little thing is based on tradition and consensus opinion -- not science.
Doctors trot out excuses about why they don't use the Internet as a tool for working with patients. I think doctors' big fear is that the online discussions with patients will eat up time, with little or no extra payment for the service.
A big impediment is that in most states it is illegal to prescribe drugs for a patient based on an online evaluation. That seems strange to me because physicians have been prescribing medicines by telephone for simple things without the safety net the computer provides.
Of course, there have been cases of inappropriate prescribing of narcotic medications in my home state, Illinois, and others. And regulators put the clamps on even legitimate use of Internet medicine without a face-to-face physical exam.
The medical establishment has been reluctant to embrace online medicine. Indeed, medical societies and the Federation of State Medical Boards have taken a very aggressive position against Internet prescribing in the name of patient safety. In their world, only in-person visits are thought to be safe.
Are the boards of medical examiners' policies really protecting patient safety or only mandating face-to-face office visits as economic protection for doctors, I wonder.
If I tried to prescribe ED drugs today based on an Internet questionnaire and email correspondence, the state medical board could take my license away and fine me thousands of dollars for every patient I treated.
I have no desire to be a Viagra prescription mill. I bring up the medicine because ED care over the Internet is probably the most studied of online options.
There are broader applications for Internet treatment beyond ED. And to be absolutely clear, there's no evidence that only face-to-face office visits are safe, effective and high-quality.
Traditionalists in medicine may be afraid to learn how good Internet medicine can be. One of the first substantial studies of Internet medicine was conducted by the University of Utah and published this month in the journal Mayo Clinic Proceedings. The researchers compared traditional office treatment of erectile dysfunction versus Internet practice.
The patients treated online had no face-to-face exam. The traditional doctors had the benefit of a computerized record system but they still lost out to the Internet doctors, who took a more thorough history and provided more counseling with the aide of a standardized Internet-based system.
Internet practice for ED was equal to traditional office practice or safer in all areas studied.
As a small-town doctor who still makes house calls, the prospect of an Internet practice is quite a departure from business as usual. As the Internet-savvy population ages and the number of primary care doctors dwindles, the demand for safe online medicine will grow.
Until the regulators come around to the advantages of Internet medicine, patients will continue to miss work over minor ailments and I'll keep seeing them at the office.
References
1. Benjamin Brewer MD, Internet Visits With Doctors Can Beat Office Appointments, August 20, 2008.
2. Mark Munger, et al, Safety of Prescribing PDE-Inhibitors via e-Medicine vs Traditional Medicine, Mayo Clin Pr0, August, 2008.
Physician-Led Hospital Turnabouts
An August 2 Boston Globe article “Cape Cod Hospital CEO Maps Turnaround.” opens:
Dr. Richard Saluzzo, the new chief executive of Cape Cod Health Care in Hyannis, says he plans to rebuild his health system’s relationship with doctors and create a “physician-led organization” as he seeks to turn around the cash strapped organization
Saluuzon says, “the medical staff leadership group is going to run this hospital with us. They will be actively involved in all decisions. Now there is suspicion and distrust between the doctors and the hospital. We need down those barriers.
I pray Dr. Saluzzo succeeds. Cape Cod needs its hospital system, not only for its care but as the Cape’s largest employer. Cape Cod Health Care employs 4000. In the year ending May 31, the system lost $24 million, partly because its doctors referred high-tech high-ticket procedures, like MRI and CT scans, to outside facilities. Another problem, says Salluzzo, is that system employs 33 hospitalists. For a system of 313 beds, this may be an excessive number. Until recently hiring hospitalists was considered the rage for most hospitals.
I find this story intriguing for personal and global reasons. I had a home in Falmouth for 20 years and was fascinated by that vacation-bound peninsula’s quirky economic climate. More broadly, it brings home the message that hospitals had better bring doctors into the decision-making process if they are to succeed. Doctors are hospitals’ main customers. Without doctors, hospitals would be empty shells with mediocre food.
Hospital financial failures are not rare, with Medicare revenues flattening, health plan reimbursement tightening, doctors setting up competitive facilities, and consumers gravitating to ambulatory settings. Turning failing hospital around requires;
• rallying doctor leaders around a common cause,
• attacking problems on multiple fronts (cutting staff, renegotiating contracts, collecting money owed, coding properly, restructuring debt, improving revenue cycles, enhancing productivity, bolstering morale, cutting supply expenses, building on strengths, and seizing key opportunities)
Turnarounds often succeed within one to two years:
• Maricopa Medical Center from $12 million debt to $25 million profit in a year,
• New England Medical Center from a $4.7 million loss to $400,000 surplus in year,
• Crouse Hospital in Syracuse from $91 million to in the black in 2 years,
• Detroit Medical Center from $60 million in losses to break even in two years.
One lesson is crystal clear. effective CEO and physician leaderships are absolutely essential If the CEO happens to be a physicians,that process may be expedited. In our book, Sailing the Seven “Cs” of Hospital-Physician Relationships: Competence, Convenience, Clarity, Continuity, Competition, Control, and Cash (PSR Publications, 2006), James Hawkins, a former hospital administrator, and I observed better physician relationships, even formal partnerships, will be required for future hospital viability and stability.
Dr. Richard Saluzzo, the new chief executive of Cape Cod Health Care in Hyannis, says he plans to rebuild his health system’s relationship with doctors and create a “physician-led organization” as he seeks to turn around the cash strapped organization
Saluuzon says, “the medical staff leadership group is going to run this hospital with us. They will be actively involved in all decisions. Now there is suspicion and distrust between the doctors and the hospital. We need down those barriers.
I pray Dr. Saluzzo succeeds. Cape Cod needs its hospital system, not only for its care but as the Cape’s largest employer. Cape Cod Health Care employs 4000. In the year ending May 31, the system lost $24 million, partly because its doctors referred high-tech high-ticket procedures, like MRI and CT scans, to outside facilities. Another problem, says Salluzzo, is that system employs 33 hospitalists. For a system of 313 beds, this may be an excessive number. Until recently hiring hospitalists was considered the rage for most hospitals.
I find this story intriguing for personal and global reasons. I had a home in Falmouth for 20 years and was fascinated by that vacation-bound peninsula’s quirky economic climate. More broadly, it brings home the message that hospitals had better bring doctors into the decision-making process if they are to succeed. Doctors are hospitals’ main customers. Without doctors, hospitals would be empty shells with mediocre food.
Hospital financial failures are not rare, with Medicare revenues flattening, health plan reimbursement tightening, doctors setting up competitive facilities, and consumers gravitating to ambulatory settings. Turning failing hospital around requires;
• rallying doctor leaders around a common cause,
• attacking problems on multiple fronts (cutting staff, renegotiating contracts, collecting money owed, coding properly, restructuring debt, improving revenue cycles, enhancing productivity, bolstering morale, cutting supply expenses, building on strengths, and seizing key opportunities)
Turnarounds often succeed within one to two years:
• Maricopa Medical Center from $12 million debt to $25 million profit in a year,
• New England Medical Center from a $4.7 million loss to $400,000 surplus in year,
• Crouse Hospital in Syracuse from $91 million to in the black in 2 years,
• Detroit Medical Center from $60 million in losses to break even in two years.
One lesson is crystal clear. effective CEO and physician leaderships are absolutely essential If the CEO happens to be a physicians,that process may be expedited. In our book, Sailing the Seven “Cs” of Hospital-Physician Relationships: Competence, Convenience, Clarity, Continuity, Competition, Control, and Cash (PSR Publications, 2006), James Hawkins, a former hospital administrator, and I observed better physician relationships, even formal partnerships, will be required for future hospital viability and stability.
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